Caring for the Transgender Patient

Transgender patients may present to dermatologists for a host of skin health and/or cosmetic issues. Doris Day, MD, a New York City dermatologist and a clinical associate professor of dermatology at the New York University Langone Medical Center, initially shared her experiences treating transgender patients at the 2019 Cosmetic Surgery Forum in Nashville.

Dermatologists’ knowledge of the unique needs of skin, facial contours, and natural aging can offer an imperative piece of a thoughtful therapy plan for transgender patients, Dr. Day says.

Laser hair removal of face and body, hair growth on scalp, and neuromodulators and fillers can help create a gender-matching profile, and body treatments can enhance contour. “It’s a combination of these rather than any one treatment that offers the best results,” Dr. Day says. “Any one treatment alone may look off-balance without the appropriate addition of the others to balance the total effect.”

Most transgender women say that their face is most important, whereas transgender men noted their chest in a 2016 study in the Journal of the American Academy of Dermatology by Dr. Day and colleagues.¹ Of women’s facial procedures, hair removal ranked number one, followed by surgery, then injectables. When choosing procedures, money was a major barrier and good aesthetic outcome the primary concern for transgender patients, the study found.

The Effects of HRT

Not all transgender patients pursue medical or surgical therapy. For those who do, hormone-induced facial effects can take more than two years to be fully evident. It is recommended that transgender patients wait two full years before undergoing facial surgeries. This is one of the reasons more patients are turning to dermatologists to more immediately experience some of the changes they are seeking, Dr. Day explains.

Moreover, changes in skin for patients undergoing feminizing hormone therapy are abundant and include reduced sebaceous gland activity, slow growing body and facial hair, smoother skin, reduced pigment production, and more. Prescribing an appropriate topical skincare regimen is an important element in their care and can help maintain healthy skin and improve self confidence, Dr. Day points out. In male patients, hormone replacement therapy can affect skin and hair. Testosterone can contribute to severe acne and male-pattern hair loss.

“It is important that we work with a multidisciplinary team, which may include plastic surgeons, endocrinologists, and psychiatrists or psychologists along with other physicians and providers,” she says. “If we have doubts or concerns about the emotional stability of our patients, we could confer with the other specialists to make sure we take the best care possible.”

Caring for transgender patients requires really listening to their needs, she says.

There is fluidity when it comes to gender identity, and we should be careful not to insert a binary view of masculine or feminine. “Let patients lead the way,” Dr. Day says. “In our conversations with the patient it is helpful to identify them as the gender they request,” she says. “It is especially important to listen and to understand their vision and goals for themselves and to work to meet that rather than to impose our views of what masculinity or femininity should be for them.”

This is different for non-transgender patients, she says. “I have to sometimes help [these patients] understand my vision for them, in adjusting their appearance slowly to match their ideal gender, without changing the essence of how they look, always being careful to avoid the caricatured look of overfilled lips or cheeks,” she says.

Respect is always paramount. “I believe we need to treat all patients with respect; it’s part of our calling as physicians. It is never our place to judge, only to guide and help our patients to the best of our ability,” she says. “Enjoy the process of helping the transformation. It is one of the most gratifying things we can do, to help our patients look on the outside the way they feel on the inside.”

1. Ginsberg BA, Calderon M , Seminara MM, Day D. A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community. Journal of the American Academy of Dermatology. 2016 Feb;74(2):303-8.